2015-2016 Dental Reference Guide

Order Form

Date _________________________________ Check Here If First Order_________________ Ordered By ____________________________ Name __________________________________________________ Phone (_______)_________________________ Fax Number: _____________________________________________ Address_________________________________________________________________________________________ City __________________________________________________________ State ___________ Zip ______________ Salesperson _____________________________________________________________________________________ Order, Pricing and Product Questions: Toll Free: 800-626-2163 Fax Order Line: 920-866-1865 Toll Free Fax: 1-888-681-5088 Account #: ______________________________________

Credit Card

Payment Method Choose One:

Bill My Account (With Approval-See Terms) (Inside front cover)

Please call the Dental Health Products, Inc. Billing Department with your credit card information. (800-626-2163)

Check-by-Phone

Qty

Item#

Size/Color

Product Name/Description

Unit Price Extended Price

Check-by-Phone Has Replaced C.O.D.'s Our customers are enthusiastic about our Check-by-Phone service. Check- by-Phone is faster than C.O.D. and saves you the $10.00 or $10.50 fee. To use Check-by-Phone just tell your Account Manager or Customer Service Representative your check information. It’s that easy! No C.O.D., no extra charge; it’s all taken care of!

Sub Total: Shipping: Fuel Surcharge: {This fuel charge will be monitored an adjusted on a regular basis.) Handling Fee: TOTAL:

$0.00 TBD

Local Delivery:__________________________ *The above amounts are subject to change.